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54-YEAR-OLD WOMAN WITH BREAST CANCER
Authored By: Asif Moinuddin and Jerold Wallis, Assoc Prof of Radiology.
Patient: 54 year old female
History: 54-year-old woman with breast cancer, being evaluated prior to further chemotherapy.
Image Size:[small][as-submitted]

Multimedia: 96937_1_submitted.avi
LAO images of the heart

Fig. 2
Processing showing EF of 21%, ED, ES, stroke, paradox images, and time activity curves.

Multimedia: 96937_3_submitted.avi
After repositioning of ECG leads

Fig. 4
Processing of repeated images, with EF of 51%
Image Size:[small][as-submitted]

Findings: On this single LAO view of the heart, the chambers contract very poorly.
The calculated ejection fraction is 21%.

What is the differential for this finding?

[pagebreak]
This could represent severe chemotherapy-induced cardiomyopathy.

What else could it be?



DDx: This could represent severe chemotherapy-induced cardiomyopathy.

However, the fact that NONE of the chambers appears to be contracting is atypical, and technical factors should be considered.   Lack of an adequate gating signal during acquisition could give this appearance.  See additional images (now available) after repositioning the ECG leads.
Diagnosis: Poor ECG gate during acquisition.
General Discussion: Most gamma camera "gating boxes" allow the user to view the ECG tracing, and to see the markings on the tracing that indicate what portion of the ECG cycle is used for gating.

In this case, the ECG tracing appeared non-physiologic, and represented cyclic respiratory muscle activity and other muscle activity rather than cardiac cycles.
Specific Discussion: RADIOPHARMACEUTICAL: 25.92 mCi Tc-99m in vivo labeled red cells i.v.
FINDINGS:

The patient was obese and the ECG leads were not properly attached to the patient’s body. Initial imaging (Fig 1 and 2) demonstrated data from non-synchronous cardiac gating which were erroneously gated with respiratory motion. Re-imaging (Fig 3 and 4) was performed after correctly positioning and attaching the ECG leads and the data was re-acquired. After correct cardiac gating, images were of diagnostic quality (though still suboptimal due the patient's large body size).    Both the right and left ventricles contract normally. The left ventricular ejection fraction is 51% (normal > 50%), which is at the lower limits of normal
Comments:
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Additional Details:

Case Number: 96937Owner(s): Asif Moinuddin and Jerold Wallis, Assoc Prof of RadiologyLast Updated: 02-07-2013
Anatomy: Cardiopulmonary   Pathology: Other
Modality: Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: canm, gating artifact, artifact, ejection fractionACR: 50000.93000

Case has been viewed 38 times.
Certified by Jerold Wallis on 04-30-2008

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